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21st Apr 2000: Chris Holdcroft
SO WHAT'S WRONG WITH THE
'REVIEW'?
by Chris Holdcroft, 21st April
2000
(updated 11th October 2000
& 11th May 2001)
Fluoridation of Drinking Water: a Systematic Review
of its Efficacy and Safety. Centre for Research and
Dissemination, University of York.
STAGE 1.
On the 16th December, 1998, the Earl Baldwin of
Bewdley addressed the House of Lords on the issue of
fluoridation. It is a subject which has failed to go
away, being debated by both supporters and opponents
of fluoridation for many years.
Only a full, uncompromising and quality reassessment
of this practice would be capable of silencing
critics from both parties who each have their own
interests in seeing fluoridation extended or
abolished. As a consequence, Baldwin lit the blue
touch-paper and stated;-
"... This is a subject I have been studying for
many years, and the predecessor of the noble
Baroness, Lady Hayman, the noble Baroness, Lady Jay,
in conversation earlier this year, urged me to put
down a Motion which could help to clarify thinking
on the subject.
There are two strands to my Motion. For the wording
of the first part I am indebted to Dr. Iain
Chalmers, the head of the UK Cochrane Centre which
has a brief for high-quality scientific evidence in
health-care, who believes that:
"a group should now be commissioned which is seen to
be independent of any particular viewpoint in order
to draft a protocol, to be endorsed by both
supporters and opponents of fluoridation, for a
scientifically defensible systematic review of the
available evidence (published and unpublished), and
that the results of such a review should be made
public".
The second strand recognises the fact that this is
not just a scientific matter, but that reaching
whole populations through the public water supply
involves questions of ethics, social policy, cost
and cost-effectiveness, appropriateness of the
decision-making process, environmental consequences,
and so on. Only through a public inquiry, in an area
where feelings have always run extraordinarily high,
can such matters be properly addressed." [Lords Hansard, Column 1394].
As Baldwin states, there are two strands to
consider. The first is that he suggests that a
review is acceptable but concludes in the second
strand that only a public enquiry will solve the
ethical implications of a possible policy of
mandatory fluoridation.
The first compromise was beginning to develop. The
findings of the Review can produce only three
possible outcomes. Either the Review [1] supports or
[2] opposes fluoridation or [3] is inconclusive. If
the second or third outcome is determined then there
shall be no mandate for compulsory fluoridation. And
if there is no conclusion, the third determination,
then it is likely that fluoridation in existing
communities is likely to continue. In any event,
there should be a public enquiry in addition to the
Review.
However, the Government has so far shown no desire
to hold a public enquiry and will seemingly rely
exclusively upon the Department of Health to pass
judgement on the Review's findings. This is not
satisfactory and allows a Government Department with
a self-confessed support of fluoridation, and often
observed cynical manipulation of fluoridation data,
to act as judge and jury.
It should also be considered that: "CRD has been
funded by the *Department of Health to carry out a
systematic review into the efficacy and safety of
the fluoridation of drinking water, as outlined in
the recent Department of Health White Paper 'Saving
Lives: Our Healthier Nation'." *NB. Funding came via
the NHS Executive.
So what value and trust can we put in a Review which
is hamstrung from the beginning?
It has been reported that Baldwin is quite pleased
to have won a review into fluoridation but we have
yet to hear the honourable gentleman campaign
further for the public enquiry which he considers
equally necessary.
STAGE 2.
The Review, which commenced in the second half of
1999, has now almost concluded it's work.
Regrettably, a number of incidents have disturbed
the equilibrium of what was supposed to be an
exercise not just in scientific research, but also
political impartiality. These incidents can be
itemised accordingly;-
The entire review process has three components.
There is the [1] Review Panel and the Review Team
members based in [2] York and [3] Cardiff. The York
and Cardiff Teams are responsible for assessing
papers. The assessment takes the form of producing
baseline data, results and validation. When this is
completed, the findings are published on the
Review's dedicated web-site. Unfortunately, the team
in Cardiff has at least one element who either
supports or is 'sympathetic' to the practice of
fluoridation and therefore should not rightly be
involved in an 'impartial' review process. The true
character of the York team is as yet undetermined.
The Review Panel is similarly supposed to be
impartial. While the Review Teams should contain
scientific researchers with no impartialities, the
Panel differs by bringing together members form
opposing camps. There is supposed to be a balance
between pro-fluoridationists and anti-fluoridationists
- but this is not strictly true. Taking into account
those I would loosely describe as 'surrogate pro-fluoridationists',
the anti-fluoridationists are outnumbered by about 7
to 3. For the record, I classify a surrogate pro-fluoridationist
as someone who does not campaign for fluoridation
but has shown support for the practice - either
directly or indirectly. One example of an indirect
endorsement has come from Pamela Taylor of the
organisation 'Water UK';-
"the decision whether to fluoridate a water
supply should lie with the health authority - the
current discretion on water operators whether to
accede to an application from a Health Authority
should be removed." As quoted by: *Baroness
Gardner of Parkes [Column 1402, Lords Hansard, 16th
December, 199 ].
*A self-confessed Australian dentist,
no less (and "... with no interest to declare.")!
Perhaps Pamela Taylor might think of herself as an
independent, I do not know. But when an individual
who represents British water companies directly
implies that she and / or they merely don't want to
reap the consequences of any responsibility (read:
potential litigations), then that is being pro-fluoridationist
in my book. After all, a paid assassin is an
accomplice in every sense of the word. Ms Taylor
could escape this accusation if she were to change
her statement to something like: "the decision
whether to fluoridate a water supply should lie with
the population affected after listening to full
representation from both genuine and informed
supporters and opponents of fluoridation."
STAGE 3.
It has been seen so far that a review into
fluoridation is insufficient and that the Review
Body as a whole is not truly representative of the
opposing factions. Regardless of the outcome of this
review, there remains one outstanding concern.
It is former Health Secretary, Frank Dobson, who
arrogantly boasted of a "once-and-for-all' review to
settle the matter of fluoridation. No doubt as a
supporter of fluoridation himself he felt relatively
confident of an outcome which supported his
distorted and ill-informed opinions.
During the early stages of this review anything but
an endorsement seemed likely. However, from day one
of the review, the narrow protocol and practices of
the Review Body have swung the review process slowly
back towards a pro-fluoride stance.
The first problem has been 'compliant'
representation from the anti-fluoridationists on the
panel. Unwilling to upset anyone, they have to
readily agreed to anything which would have
strengthened the anti-fluoridation campaign and have
ensured a greater level of impartiality. The first
example is animal studies. While being an
anti-vivisectionist myself, one of the few times
animal studies would have actually done some good
was by being admitted for study analysis. Either way
these studies would have been, [1] discredited and
once again have shown such 'scientific' experiments
to be worthless or, [2] have supported the
anti-fluoridation campaign and society as a whole by
showing that artificial fluorides are toxic even in
minute quantities. But animal studies were omitted
from the review process! The main verbal excuse of
the Review Body is that they had insufficient
resources to consider both human AND animal studies
due to the vast workload this would have imposed
within such a short time. The minutes of the
meetings of the Review Panel indicated that animal
studies were deemed to be unreliable and this is the
excuse that was used to omit such studies.
Considering that the final report of the CRD stated
the human studies they had considered were of poor
quality is somewhat hypocritical.
The next problem to emerge was a further restriction
on study qualification. The quality of work
submitted on caries studies in particular is grossly
inadequate. It has been observed that the main
pitfall of these studies is failure to allow for
confounding factors. However, this is not surprising
as you cannot put humans into a controlled
environment unless you treat them as laboratory
animals. Another factor is that with caries studies
in particular, you can never account for
'background' influences in fluoridation trials. For
example, Brown's 1962 caries study stated: "the
recordings so far obtained indicate both a high
treatment and an apparently better oral hygiene
status of the Brantford (fluoridated) children
when compared with the controls, and it is therefore
suggested that caution should be exercised in the
interpretation of the rates shown. The lack of a pre
fluoridation survey on a comparable basis is a
further limiting factor in interpreting the
results." Source: The Ecologist, Page 233,
Volume 16, No. 6, 1986.
This statement STRONGLY emphasises my point that
fluoridation studies can be given a helping hand by
virtue of greater support for children living in
fluoridated areas as opposed to those living in
non-fluoridated areas. This claim is further
supported by another story from the same magazine
involving a manipulated New Zealand study and
entitled: "The Hastings Fluoridation Experiment:
Science or Swindle?"
In an attempt to analyse the alleged true effect of
water fluoridation on populations, I conducted a
desktop exercise where I theoretically 'removed'
fluoride (both natural and artificial) from all
supplies in England. By looking at dmft levels after
the removal of fluoride and then comparing them to
what would be expected to be observed for each
individual community (after allowing for social
status), it would be possible to see which
communities would normally observe better dental
health. Although it was an exercise it was a very
useful one and showed that there were very strong
regional variations in dental health and
sufficiently proved that you cannot compare
different communities from different regions - even
where the social status is similar (such as equally
deprived districts in London, the Midlands and the
North West). Even Marian McDonagh of the CRD's York
team admitted it was a good piece of work.
The difficulty I encountered was that despite the
quality of my work and the important information it
imparted - it did not meet the protocol of the
Review! Furthermore, some ad hoc observations which
I included in my study were acceptable and published
as a separate study by the Review Body. This was not
my original intention and I would not have pushed
for their inclusion until I saw a similar submission
appear on the Review's web-site. This was a piece of
work by 'Gray', dated the year 2000, and was listed
as 'notes' on changes in dental health in the West
Midlands. Because my 'notes' were based on the same
data, I decided to submit them as well (what's
sauce for the goose, etc.).
My original understanding was that these notes, from
both myself and Gray, would not be treated as proper
studies - but that is what happened. Expecting only
a mention of these notes in the Review Body's final
report, I was amazed to see them presented as a
'stand-alone' study and rated as joint-2nd in the
their respective validation table! I find it very
embarrassing that a few pages dedicated to basic
observations should receive such an accolade and I
did try to get them withdrawn. I am told this work
will not be excluded. The icing on this very sickly
slice of cake is contained in the following
statement;-
"We are sorry that you feel this way, but cannot
remove this material as censorship such as this
would severely undermine the integrity of the
review. One of the fundamental principles of
conducting systematic reviews is the rigorous
attempt to include all studies, published or
unpublished. As your material was submitted and met
inclusion criteria, we cannot justify removing it
now." Marian McDonagh, 20th April, 2000.
The third and final problem concerns the lack of
inclusion of data which emphasises other confounding
factors. I have personally submitted data on
receipts, treatments, capitations and community
support for children under-18 and since mid-1997.
This data is very comprehensive and covers every
child in England who has been registered with a
dentist and who has also received treatment.
Expenditure on child treatments has also been
provided.
This data makes a substantial contribution to the
Review and I was led to think that it would be taken
into consideration towards the end of the review
process. At the '11th hour' I have been informed it
will not be included in the final report. All I can
say about this episode is that if this is the way
the Review Body is going to present evidence to the
Department of Health, then god help us all.
STAGE 4.
This chapter is a short one. It evaluates the
evidence so far and the potential outcome of the
review process.
There are numerous shortcomings. A narrow protocol,
poor quality submissions, a seemingly heavily biased
Review Panel whose members hardly ever seem to know
what the Review Team at York is doing or planning,
late changes to inclusions in the final report, etc.
Isn't there enough here to make the reader wonder
where the review process is going?
The final hurdle to be cleared now the draft report
is out is the nomination of peer reviewers. Each
faction can nominate three candidates. But who in
their right mind would want to put their name to
such a review? There still exists a great potential
for this review to be twisted, turned, spun and
reconstituted to the benefit of the supporters of
fluoridation. And it is because the anti-fluoridationists
have been so successfully sucked in that they risk
not only damaging the cause but also their own names
and the names of those they wish to stand as peer
reviewers.
Life is a gamble. As an experienced gambler, and
chess player, I have learned that all eventualities
have to be taken into consideration, assessed and
weighted accordingly. When the odds are stacked
against you do not gamble - its as simple as that.
This translates as the following: the review is no
longer a worthy risk. The representatives of the
anti-fluoridation movement who sit on the Review
Panel, Messrs. Baldwin, Gibson and Mansfield, should
pull out now.
STAGE 5.
The worst fears of the anti-fluoridationists have
been realised. The politically correct Press Release
issued by the CRD on the 6th October 2000 confirms
this.
Careful to chose their words and terminology, the
press release has allowed the media to generally
interpret the final report of the CRD as an
endorsement for fluoridation.
But what else could we expect? A non-independent
review into water fluoridation which has omitted so
much important evidence has produced a final report
which made very dubious claims based on bad science.
So where's the credibility in all of this?
INTERESTING NOTES.
E-Mail To;-
Marian S. McDonagh, PharmD
Research Fellow in Health Services
NHS Centre for Reviews and Dissemination
University of York, England
Dear Marian
Thank you for your e-mails of 14/4/2000. However, I
am still concerned about three major points.
It is obvious the draft report does not yet mention
the DPB / CDS data (receipts, community services,
etc.). Unless it is provided as a supplement to the
Draft Report then it obviously cannot be reviewed
externally. Therefore, what provisions does the
Review Body intend to make so that this data can be
examined and commented upon before the Final Report
is published? The following quote from Brown's 1962
caries study may also be of interest to you;-
"the recordings so far obtained indicate both a high
treatment and an apparently better oral hygiene
status of the Brantford (fluoridated) children
when compared with the controls, and it is therefore
suggested that caution should be exercised in the
interpretation of the rates shown. The lack of a
pre-fluoridation survey on a comparable basis is a
further limiting factor in interpreting the
results." Source: The Ecologist, Page 233, Volume
16, No. 6, 1986.
This statement STRONGLY emphasises my point that
fluoridation studies can be given a helping hand by
virtue of greater support for children living in
fluoridated areas as opposed to those living in
non-fluoridated areas. This claim is further
supported by another story from the same magazine
involving a manipulated New Zealand study and
entitled: "The Hastings Fluoridation Experiment:
Science or Swindle?"
My second point is that the observations I made on
changes in 'dmft' levels in the West Midlands,
1985-95, were general notes only. As you are aware,
it was not intended as a 'stand alone' study and
therefore I should have (yes, my fault!)
previously insisted that they be represented in a
slightly different way. As a consequence, and before
the Final Report is published, I would like
something along the lines of the following to be
added;-
"The data submitted by Holdcroft (1999)
represented only a small part of a larger study
which did not meet the Protocol of the Review
Process. This larger study considered numerous
aspects of dental health in England where fluoride
is assumed effective and removed from all water
supplies."
NB. The Jarman Scores I used were from the 1991
census (from the 1995 Public Health Common Data Set) and published by Pitts N B & Palmer J D (BASCD,
1995). Apologies for not making that clear.
My third and final point is this. What allowances
have you made for other flaws in caries studies
bearing in mind the observations I made in my
interim study entitled: "Dental Health Expenditure
in England, 1998 to 1999. The correlation between
NHS expenditure, Community Dental Services and the
findings of the British Association for the Study of
Community Dentistry"?
I refer to differences in natural and artificial
water supplies and the fact that potentially
seriously damaged teeth are counted as 'sound' if
the damage is attributable to excess fluoride
consumption.
Yours sincerely
Chris
Re: my e-mail to Marian McDonagh on 14/04/00
......
From: Paul Wilson, NHS Centre for Reviews &
Dissemination. 17/4/00
... no economic studies/data will be presented in
the review because a systematic search of these has
not been undertaken.
Evidence of lack of support from the anti-fluoridationists
for the Review process ......
Peter Mansfield. 14/4/00, e-mail reply.
... As to representativeness (sic), I am constantly
reminded that I represent nobody but myself in this
review advisory process. Actually it's easier that
way.
Evidence of interference from the DoH ( why
did they want to delay publication of the final
report? ).
10:06 am, 20th September
Hi Chris
The Department of Health has been in contact with
the BMJ and requested to postpone publication until
the issue of 7th October to which the BMJ has
agreed. ...
Paul Wilson, NHS Centre for Reviews & Dissemination
Salient Points;-
- The Protocol of the 'Review' was altered and
as a consequence rejected a great deal of
important evidence.
- The 'anti-fluoridationists' on the Review
Panel were ineffective, weak and compliant - and
did not have the support of the anti-fluoridation
lobby. They were also effectively outnumbered 7-3.
- My own evidence of other interventions in dmft
(decayed, missing & filled teeth) studies was
refused consideration. It is easy to improve dmft
rates if you know the tricks of the trade and you
want to make it appear that fluoride in water is
the sole reason for such improvements.
- My own dmft study was misrepresented and taken
out of context.
- The Review reported that their findings were
based on poor quality research. One of the papers
which was open to bias and only achieved an
average rating was the one written by Phipps.
Phipps study commenced in 1986 and finished in
1995 - so why has it taken so long for this
American study to see the light of day and why was
it not previously published in an American
scientific Journal? Perhaps it was not of adequate
quality - yes?
- The claim of 2.25 teeth saved is subject to
serious question as methods used to measure dmft (in the UK at least) counts badly fluorosed teeth
as being sound and present (see pictures).
And as with my 2nd point, other interventions were
deliberately not evaluated.
- The Review reported that 48% of an exposed
population would be afflicted by fluorosis of
which 12.5% would be badly affected. Nothing
mentioned about the psychological trauma caused to
children I note.
- Fluorosis is also a condition which costs a
King's ransom to temporarily cosmetically conceal
- lots of extra cash for the dentists I would say.
After all, what would you like to do, fill or pull
a few teeth for a few quid or rake in £100's or
£1,000s for cosmetic treatments?
- The BMJ (British Medical Journal)
deliberately picked out the Phipps study for
publication when it could easily have picked a
better study. But the BMJ is notoriously
pro-fluoride.
- The Review's authors the CRD (Centre for
Reviews and Dissemination) at York also failed to
mention that three peer reviewers heavily
criticised the Review's findings.
- The CRD's boast that the Review's findings
were "the final word on fluoride" is outrageous
and a classic example of an exercise in controlled
propagandist disinformation. The final word on
fluoride does not lie with the CRD - it lies with
the victims of fluoride poisoning.
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